Active Surveillance for PCa: Past, Current, and Future Trends

Active Surveillance for Prostate Cancer: Past, Current, and Future Trends (2023, Full Text)

Authors at the Department of Urology, Erasmus MC Cancer Institute, University Medical Center Rotterdam

"Abstract

In response to the rising incidence of indolent, low-risk prostate cancer (PCa) due to increased prostate-specific antigen (PSA) screening in the 1990s, active surveillance (AS) emerged as a treatment modality to combat overtreatment by delaying or avoiding unnecessary definitive treatment and its associated morbidity. AS consists of regular monitoring of PSA levels, digital rectal exams, medical imaging, and prostate biopsies, so that definitive treatment is only offered when deemed necessary. This paper provides a narrative review of the evolution of AS since its inception and an overview of its current landscape and challenges. Although AS was initially only performed in a study setting, numerous studies have provided evidence for the safety and efficacy of AS which has led guidelines to recommend it as a treatment option for patients with low-risk PCa. For intermediate-risk disease, AS appears to be a viable option for those with favourable clinical characteristics. Over the years, the inclusion criteria, follow-up schedule and triggers for definitive treatment have evolved based on the results of various large AS cohorts. Given the burdensome nature of repeat biopsies, risk-based dynamic monitoring may further reduce overtreatment by avoiding repeat biopsies in selected patients.

1. Introduction

2. History and Establishment of Active Surveillance Studies

3. Evidence for Active Surveillance from Randomised Controlled Trials Comparing Definitive Treatment and Observation

4. Evolution of Active Surveillance Inclusion Criteria and Intervention Triggers

5. Current Guideline Recommendations and Uptake of AS

6. Barriers to Uptake and Compliance of Active Surveillance

7. Risk-Based Follow-Up in Active Surveillance

8. Conclusions

Over the last 25 years, AS has evolved and is now a standard of care strategy in the management of low-risk PCa and can also be considered in selected patients with favourable intermediate-risk disease. Although the uptake of AS has increased over the years, barriers to the uptake and compliance of AS remain. As patient selection is improved and personalised, dynamically adaptive follow-up becomes available, and men may require less invasive monitoring in the future so that overtreatment can be reduced even further."
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See especially:

Table 1. Protocol-driven, prospective active surveillance cohorts.

Table 2. Current guideline recommendations on active surveillance.

Table 3. Prediction models for reclassification in active surveillance.

I believe you're right about PSMA PET playing a role in AS eventually. I don't know how long that will take, though, as insurance will only pay for men who are "on label" for the PSMA PET. There is another PSMA PET likely to be FDA approved later this year, but it won't be for Low Risk PC - I believe it will be for Intermediate Risk.

I still think we need to help people understand that no medical imaging is 100% accurate. I think it's a good question to ask your doctor - how accurate is this imaging? Multiparametric MRI in the hands of an expert (and with a comparison to previous) is still very, very good - the best imaging we've had so far for prostate, prostate bed, and seminal vesicles. (not lymph nodes necessarily). But everyone wants good imaging for their cancer, of course...everyone.

Yeah - I suspect you're right. No idea how long that might take.
The Pylarify FDA Label says it is for PC patients:

"* with suspected metastasis who are candidates for initial definitive therapy.
* with suspected recurrence based on elevated serum prostate-specific antigen (PSA) level. (1)"

https://www.pylarify.com/prescribing-information.pdf

Right - great news for patients...